- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.27 / $1,163.59 / $1,667.21
| Professional | | $889.27 | $1,163.59 | $1,667.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.18 / $1,527.76 / $2,293.25
| Professional | | $1,083.18 | $1,527.76 | $2,293.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.51 / $1,489.90 / $2,345.21
| Professional | | $1,040.51 | $1,489.90 | $2,345.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,915.46 / $10,915.46 / $10,915.46
| Professional | | $10,915.46 | $10,915.46 | $10,915.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.86 / $1,292.58 / $2,372.80
| Professional | | $1,009.86 | $1,292.58 | $2,372.80 |